Ambulatory Pediatrics
Volume 4, Issue 1 , Pages 55-63 , January 2004

Reducing Errors and Promoting Safety in Pediatric Emergency Care

  • James M. Chamberlain, MD

      Affiliations

    • From the Division of Emergency Medicine (Dr Chamberlain), Children's Hospital, George Washington University School of Medicine, Washington, DC; Division of Critical Care Medicine (Dr Slonim), George Washington University School of Medicine, Washington, DC; and Health Services and Community Research (Dr Joseph), Children's National Medical Center, George Washington University School of Medicine, Washington, DC
    • Corresponding Author InformationAddress correspondence to James M. Chamberlain, MD, Children's National Medical Center, Emergency Medicine, 111 Michigan Ave NW, Washington, DC
  • ,
  • Anthony Slonim, MD, MPH

      Affiliations

    • From the Division of Emergency Medicine (Dr Chamberlain), Children's Hospital, George Washington University School of Medicine, Washington, DC; Division of Critical Care Medicine (Dr Slonim), George Washington University School of Medicine, Washington, DC; and Health Services and Community Research (Dr Joseph), Children's National Medical Center, George Washington University School of Medicine, Washington, DC
  • ,
  • Jill G. Joseph, MD, PhD

      Affiliations

    • From the Division of Emergency Medicine (Dr Chamberlain), Children's Hospital, George Washington University School of Medicine, Washington, DC; Division of Critical Care Medicine (Dr Slonim), George Washington University School of Medicine, Washington, DC; and Health Services and Community Research (Dr Joseph), Children's National Medical Center, George Washington University School of Medicine, Washington, DC

Received 24 June 2003 ,Accepted 15 October 2003.

REFERENCES 

  1. Donabedian A . Explorations in Quality Assessment and Monitoring: The Definitions of Quality and Approaches to Its Assessment . Ann Arbor, MI: Health Administration Press; 1980;
  2. Institute of Medicine. . To Err is Human: Building a Safer Health System . Washington, DC: National Academy Press; 2000;
  3. Institute of Medicine. . Crossing the Quality Chasm: A New Health System for the 21st Century . Washington, DC: National Academy Press; 2001;
  4. Reason J . Human Error . New York: Cambridge University Press; 1990;
  5. Cole T . Medical errors vs. medical injuries: physicians seek to prevent both . JAMA . 2000;284:2175–2177
  6. The Leapfrog Group for Patient Safety. . Patient safety: a time for leaps . Available at: www.leapfroggroup.org/safety.htm Accessed May 5, 2003.
  7. Leape LL , Bates DW , Cullen DJ , et al.   Systems analysis of adverse drug events . JAMA . 1995;274:35–43
  8. Wears RL , Leape LL . Human error in emergency medicine . Ann Emerg Med . 1999;34:370–372
  9. Barach P , Moss F . Delivering safe health care . BMJ . 2001;323:585–586
  10. Perrow C . Normal Accidents . New York: Basic Books; 1984;
  11. McNutt RA , Abrams R , Aron DC . Patient safety efforts should focus on medical errors . JAMA . 2002;287:1997–2001
  12. Sentinel Event Policy and Procedures . Available at: www.jcaho.org/accredited+organizations/hospitals/sentinel+events/reporting+alternatives.html Accessed May 4, 2003.
  13. Wears RL , Janiak B , Moorhead JC , et al.   Human error in medicine: promise and pitfalls, part 2 . Ann Emerg Med . 2000;36:142–144
  14. Ternov S . The human side of medical mistakes . In: Spath PL editors. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety . San Francisco, CA: Jossey-Bass; 2000;
  15. McCaig LF , Ly N . National Hospital Ambulatory Medical Care Survey: 2000 Emergency Department Summary Advance Data from Vital and Health Statistics, No. 326 . Hyattsville, Md: National Center for Health Statistics; 2001;
  16. Richardson LD , Asplin BR , Lowe RA . Emergency department crowding as a health policy issue: past development, future directions . Ann Emerg Med . 2002;40:388–393
  17. Emergency departments: unevenly affected by growth and change in patient use HRD-93-4 . Available at: www.gao.gov 1993; Accessed May 5, 2003.
  18. Richardson LD , Hwang U . America's health care safety net: intact or unraveling? . Acad Emerg Med . 2001;8:1056–1063
  19. Shaw KN , Lavelle JM . VESAS: a solution to seasonal fluctuations in emergency department census . Ann Emerg Med . 1998;32:698–702
  20. Goldstein A . Frantic Over Scarlet Fever Parents'/Fears Are Out of Proportion to Threat, Doctors Say . Washington Post . January 24, 2001;B3
  21. Sharma V , Dowd D , Swanson DS , et al.   Influence of the news media on diagnostic testing in the emergency department . Arch Pediatr Adolesc Med . 2003;157:257–260
  22. Samkoff J , Jacques C . A review of studies concerning effects of sleep-deprivation and fatigue on residents' performance . Acad Med . 1991;66:687–693
  23. Gaba DM , Howard SK . Fatigue among clinicians and the safety of patients . N Engl J Med . 2002;347:1249–1255
  24. Kozer E , Scolnik D , Macpherson A , et al.   Variables associated with medication errors in pediatric emergency medicine . Pediatrics . 2002;110:823–826
  25. Reed M, Ginsburg PB. Behind the times: physician income, 1995–99. Data Bulletin Results from HSC Research (Center for Studying Health System Change, Robert Wood Johnson Foundation). 2003:24
  26. Forster AJ , Stiell I , Wells G , et al.   The effect of hospital occupancy on emergency department length of stay and patient disposition . Acad Emerg Med . 2003;10:127–133
  27. Croskerry P . Achieving quality in clinical decision making: cognitive strategies and detection of bias . Acad Emerg Med . 2002;9:1184–1204
  28. Kaushal R , Bates DW , Landigran C , et al.   Medication errors and adverse drug events in pediatric inpatients . JAMA . 2001;285:2114–2120
  29. McCormick MC , Kass B , Elixhauser A , et al.   Annual report on access to and utilization of health care for children and youth in the United States—1999 . Pediatrics . 2000;105(1 Part 3):219–230
  30. Brennan TA , Leape LL , Laird NM , et al.   Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I . N Engl J Med . 1991;324:370–376
  31. Slonim AD , LaFleur BJ , Ahmed W , Joseph JG . Hospital-reported medical errors in children . Pediatrics . 2003;111:617–621
  32. Leape LL , Brennan TA , Laird NM , et al.   The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II . N Engl J Med . 1991;324:377–384
  33. Thomas EJ , Studdert DM , Burstin HR , et al.   Incidence and types of adverse events and negligent care in Utah and Colorado . Med Care . 2000;38:261–271
  34. Selbst SM , Fein JA , Osterhoudt K , Ho W . Medication errors in a pediatric emergency department . Pediatr Emerg Care . 1999;15:1–4
  35. Fernandes C, Wuerz R, Clark S et al. How reliable is emergency department triage? Ann Emerg Med 199:34;141-147
  36. Bergeron S , Gouin S , Bailey B , et al.   Comparison of triage assessments among pediatric registered nurses and pediatric emergency physicians . Acad Emerg Med . 2002;9:1397–1401
  37. Walsh-Kelly C , Hennes H , Melzer-Lange M . False-positive radiographic interpretations in a pediatric emergency department: clinical and economic impact . Am J Emerg Med . 1997;15:354–356
  38. Klein E , Koenig M , Diekema D , et al.   Discordant radiographic interpretation between emergency physicians and radiologists in a pediatric emergency department . Pediatr Emerg Care . 1999;15:245–248
  39. Segal GS , Chamberlain JM . Resource utilization and contaminated blood cultures in children for occult bacteremia . Arch Pediatr Adolesc Med . 2000;154:469–473
  40. Slonim AD . Cardiopulmonary resuscitation outcomes in children . Crit Care Med . 2000;28:3364–3366
  41. Seidel JS , Hornbein M , Yoshiyama K , et al.   Emergency medial services and the pediatric patient: are the needs being met? . Pediatrics . 1984;73:769–772
  42. Luten R , Wears RL , Boselow J , et al.   Managing the unique size-related issues of pediatric resuscitation: reducing cognitive load with resuscitation aids . Acad Emerg Med . 2002;9:840–847
  43. Slishman S , Sapien R , Crandall CS . Introducing a simple, weight-based, color-coded, medication dosing device . Pediatr Emerg Care . 2002;18:212–215
  44. Shah AN , Frush K , Luo X , Wears RL . Effect of an intervention standardization system on pediatric dosing and equipment size determination: a crossover trial involving simulated resuscitation events . Arch Pediatr Adol Med . 2003;157:229–236
  45. Kovacs G , Bullock G , Ackroyd-Stolarz S , et al.   A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance . Ann Emerg Med . 2000;36:301–309
  46. Nadel FM , Lavelle JM , Fein JA , et al.   Teaching resuscitation to pediatric residents: the effects of an intervention . Arch Pediatr Adolesc Med . 2000;154:1049–1054
  47. Morey JC , Simon R , Jay GD , et al.   Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project . Health Serv Res . 2002;37:1553–1581
  48. Bates DW , Leape LL , Cullen DJ , et al.   Effect of computerized physician order entry and a team intervention on prevention of serious medication errors . JAMA . 1998;280:1311–1316
  49. Bates DW , Teich JM , Lee J , et al.   The impact of computerized physician order entry on medication error prevention . J Am Med Inform Assoc . 1999;6:313–321
  50. Evans RS , Pestotnik SL , Classen DC , et al.   A computer-assisted management program for antibiotics and other antiinfective agents . N Engl J Med . 1998;338:232–238
  51. Teich JM , Merchia PR , Schmiz JL , et al.   Effects of computerized physician order entry on prescribing practices . Arch Intern Med . 2000;160:2741–2747
  52. The Leapfrog Group for Patient Safety. . Computer physician order entry . Available at www.leapfroggroup.org Accessed May 5, 2003.
  53. Chamberlain JM , Patel KM , Ruttiman UE , Pollack MM . Pediatric Risk of Admission (PRISA): a measure of severity of illness for assessing the risk of hospitalization from the emergency department . Ann Emerg Med . 1998;32:161–169
  54. Gloor JE , Kissoon N , Joubert GI . Appropriateness of hospitalization in a Canadian pediatric hospital . Pediatrics . 1993;91:70–74
  55. Soulen JL , Duggan AK , DeAngelis CD . Identification of potentially avoidable pediatric hospital use: admitting physician judgement as a complement to utilization review . Pediatrics . 1994;94:421–424
  56. Chamberlain JM , Pollack MM . A method for assessing emergency department performance using patient outcomes . Acad Emerg Med . 1998;5:986–991
  57. White Paper on Appendicitis. . Pediatric Health Information System . Shawnee Mission, KS: Child Health Corporation of America; 2001;
  58. The Leapfrog Group for Patient Safety. . Evidence based hospital referral . Available at: www.leapfroggroup.org/factsheets/ehr_factsheet.pdf Accessed May 5, 2003.
  59. Marx D , Slonim AD . Assessing patient safety risk before the injury occurs: an introduction to socio-technical probabilistic risk modeling in healthcare . Qual Saf Health Care . 2003;12(suppl 2):II33–II38
  60. Van der Schaaf TW . Medical applications of industrial safety science . Qual Saf Health Care . 2002;11:205–206
  61. Guagliardo MF , Teach SJ , Huang ZJ , et al.   Racial and ethnic disparities in pediatric appendicitis rupture rate . Acad Emerg Med . 2003;10:1218–1227
  62. Reis BY , Mandl KD . Time series analysis for syndromic surveillance . BMC Med Inform Decis Mak . 2003;3:2–12
  63. Reis BY , Pagano M , Mandl KD . Using temporal context to improve biosurveillance . Proc Natl Acad Sci USA . 2003;100:1961–1965
  64. Brenner RA , Scheidt PC , Rossi MW , et al.   Injury surveillance in the ED: design, implementation, and analysis . Am J Emerg Med . 2002;20:181–187
  65. McKay MP . Emergency physicians and emerging technologies: special crash investigations . Ann Emerg Med . 2003;41:578–579

PII: S1530-1567(05)60270-5

doi: 10.1367/1539-4409(2004)004<0055:REAPSI>2.0.CO;2

Ambulatory Pediatrics
Volume 4, Issue 1 , Pages 55-63 , January 2004